An
Annotated Review of the Evidence Base for Psychosocial and Psychopharmacological
Interventions for Children with Attention-Deficit/Hyperactivity Disorder,
Major Depressive Disorder, Disruptive Behavior Disorders, Anxiety Disorders,
and Posttraumatic Stress Disorder

A systematic search for peer-reviewed empirical studies
of childhood posttraumatic stress disorder (PTSD) was conducted using
PsycINFO and Medline electronic databases. Studies that met the following
criteria were included in the final report: (1) identified in the electronic
database by one or more of the following study descriptors: treatment
outcome study, clinical trial, controlled clinical trial, or randomized
controlled trial; (2) included subjects between the ages of 6 and 12
as the primary treatment target population, although studies that included
younger children and adolescents were not excluded; (3) published between
1985 and 1999; and (4) published in the English language. Reference
lists from review articles and book chapters were also searched. This
strategy identified 58 potential empirical peer-reviewed studies. This
number was reduced by excluding studies that were not primarily concerned
with treatment outcome and studies that had neither controlled nor quasi-experimental
designs. This left five peer-reviewed controlled studies of psychosocial
treatment for children with PTSD. No controlled psychopharmacological
studies were found. These studies are presented in table 5.

In these five studies, treated children had either a PTSD
diagnosis or PTSD symptoms. The identified trauma treated in three of
the studies was sexual abuse; earthquake victims and a mix of trauma
types (excluding abuse) were the subjects of the other two studies.
The most common research design was an RCT and there were one each of
a quasi-experimental and single case study series design. The interventions
were time-limited, provided individual or group therapy, and were cognitive-behavioral
in orientation. The largest study had a sample of 100 children, 2-year
followup, and treatment arms that included parent treatment. In general,
positive findings, such as decreased severity or number of PTSD symptoms,
were reported. Manualized interventions were developed for several of
these studies, creating the potential for replication.

Both the relatively recent recognition of PTSD in children
and the measurement of it may partially account for the limited clinical
research on this disorder. The psychosocial treatment literature for
children with PTSD is at a very early stage, and pharmacological research
is nonexistent. This limited evidence base, considering the small number
of studies, is further characterized by relatively small sample sizes
(a range of 15 to 100 subjects), precluding further analysis by gender
or racial/ethnic group, despite diversity in these study samples. The
current status of PTSD treatment research suggests both further treatment
development and controlled replications of the two well-delineated interventions
identified as cognitive behavior therapy as next steps.

RCT; the final sample
of 80 children were randomly assigned to 10-week index (n =
48) and comparison treatment group (n = 32); both
received group sexual abuse treatment; the index group also received
stress inoculation training and gradual exposure treatment

Children referred by parents,
child protective services, juvenile justice, health and mental
health providers; all with a history of sexual abuse and 81% with
a chart diagnosis of PTSD

Age: 4  13

Gender:
11% boys
89% girls

Race/Ethnicity:
74% White
11% African American
6% Hispanic
9% Other

Improvement over time
on a variety of symptoms; no differences between groups in improvement
on fear and anxiety symptoms; at the 2-year followup the majority
of children in both groups reverted to baseline levels

One-third of recruited
children did not complete treatment sessions; completers and noncompleters
did not differ on key case variables; multiple statistical comparisons
were conducted without correction for Type II error

Girls who experienced
sexual abuse in the past 3-year period recruited mostly from a
pediatric emergency clinic in a public hospital; PTSD symptoms
assessed, but no diagnosis reported

Age: 8  13

Gender:
100% girls

Race/Ethnicity:
75% African American
22% White
3% Hispanic

PTSD symptoms decreased
in both groups; abuse-related caretaker support increased; caretaker
blame and expectations of negative impact on child decreased in
the Recovering from Abuse Program at treatment termination

For the experimental condition,
therapists received a 3-hour training session, had weekly supervision,
and had access to a training manual; one-third of families dropped
out of treatment; adjustment problems were greater at baseline
in the control group

School-aged sexually abused
children were referred by child welfare agencies and presenting
with at least three PTSD symptoms; 71% had a PTSD diagnosis based
on standardized interview

Age: 7  13

Gender:
17% boys
83% girls

Race/Ethnicity:
72% White
20% African American
6% Hispanic
2% Other

Posttreatment for children
assigned to experimental conditions; PTSD and depressive symptoms
and externalizing behavior decreased more than for control groups;
greater use of effective parenting skills observed in the experimental
groups; symptom findings held up through the 2-year followup

In addition to PTSD symptoms
or diagnosis, other co-occurring disorders were common

Goenjian et al., 1997

Quasi-experimental design;
assessed individual and group trauma/grief focused psychotherapy
over 6 weeks among adolescents with PTSD who were victims of the
1988 earthquake in Armenia; students in two schools (n
= 35) received psychotherapy vs. students at two other
schools (n = 29) who did not

Students identified with
posttraumatic stress and depressive reactions 1.5 years following
an earthquake

Age: 11  13

Gender:
60% boys
40% girls

Race/Ethnicity:100% Armenian

Three years after the
earthquake, students who received the intervention reported reduced
severity of PTSD and depressive symptoms; those not receiving
psychotherapy reported increased severity of PTSD and depressive
symptoms; at baseline the rate of PTSD in the index group was
60% and 52% for controls; at followup, rates were 28% and 69%,
respectively

Although small sample
size, the direction of the findings for both groups underscore
the importance of this brief intervention

Among treatment completers,
57% no longer met criteria for PTSD at treatment termination;
86% were free of PTSD at the 6-month followup; improvement also
observed for depression, anxiety, and anger symptoms

An initial efficacy study;
children with chronic abuse-related PTSD were excluded because
family and other relevant interventions not included; conducting
a randomized clinical trial may be the next step for this intervention